Is it Permissible to Institutionalize Parents with Alzheimer’s Disease?Responsa in a Moment: Volume 10, Issue No. 5, February 2016

In memory of my father and teacher, Rabbi Noah Golinkin z”l On his 13th yahrzeit, 25 Adar I, 5776

Question: Is it permissible to institutionalize parents with Alzheimer’s disease?

Responsum: Indeed, the number of people suffering from Alzheimer’s and similar diseases increases from year to year as a result of the increase in life expectancy. For example, this was the number of such patients in the U.S.in 2014: 11% of the people age 65 or older, which is 5 million people; 32% of the people aged 85 or older (2014 Alzheimer’s Facts and Figures, p. 16, at www.alz.org, and cf. Muriel Gillick, Tangled Minds listed in the Bibliography below).Therefore, this question presents us with a difficult and growing moral dilemma. On the one hand, the Torah commands us to “Honor your father and your mother” (Exodus 20:12, Deuteronomy 5:16), which, according to our Sages, means to attend to all of the physical needs of an aging parent: “… what is honor? To feed and give drink, to clothe and cover up, to bring inside and to take out” (Kiddushin 31b). This mitzvah seems to be an absolute requirement, regardless of a parent’s behavior. On the other hand, if the parent has deteriorated to such an extent that he or she requires being sedated or having a diaper changed, is it “honor” for a child to do this? Or is it greater honor for an outsider to do so? What about the emotional strains on the child? How much must he or she bear?

This sounds like a new dilemma but, in fact, the problem of parents who have deteriorated mentally is mentioned in Jewish sources as early as the second century BCE, and the specific question raised above has been hotly debated by halakhic authorities for over 800 years.

The apocryphal book of Ben Sira, written in the Land of Israel in the second century BCE, tells us (3:11-12):

The Talmud does not explicitly deal with our issue, but it contains three passages which discuss the erratic behavior of parents. It should be noted that two of the three sources which we shall bring below are Aggadot or stories. This is not unusual. Halakhic authorities frequently rely on Aggadot when there are no halakhic sources (There is a vast literature on this topic. See, for example, Rabbi Zvi Hirsch Hayyot (Chajes), Kol Sifrei Maharatz Hayyot, Vol. 1, pp. 243-253).Indeed, when it comes to the topic of honoring parents, many of the Halakhot (laws) in the Shulhan Arukh are based onAggadot in the Talmud (See Gerald Blidstein, Honor Thy Father and Thy Mother, New York, 1975, pp. 43-46).Here are the sources:

1a. Dama ben Netina was the non-Jewish Head of the City Council of Ashkelon in the first century CE. It is related about him in the Babylonian Talmud (Kiddushin 31a):

When Rav Dimi came [from Eretz Yisrael to Bavel] he said: Once, [Dama ben Netina] was wearing a golden silk garment and sitting among the great ones of Rome [i.e. the City Council of Ashkelon], and his mother came and tore it off of him, hit him on the head and spat in his face, but he did not shame her.

1b. A similar story appears in the Talmud Yerushalmi (Kiddushin, Chapter 1, fol. 61b):

How far does honoring a parent go? He said to them: You ask me!? Go ask Dama ben Netina. Dama ben Netina was the Head of the City Council. Once, his mother was hitting him [with a shoe] in front of his Council and her shoe fell from her hand. He handed it to her so that she should not be upset.

1c. And in the parallel passage in Devarim Rabbah 14:1 we read:

Go and see what Dama ben Netina did in Ashkelon. His mother was mentally deficient, and she was hitting him…

Similarly, it is related in the Babylonian Talmud (Kiddushin 32a):

They asked Rabbi Eliezer: “To what extent must one honor one’s father and mother?” He replied: “To the extent that if he takes a wallet and throws it in the sea in your presence, you should not shame him”.

These two Talmudic passages were codified by Maimonides (HilkhotMamrim 6:7) and Rabbi Joseph Karo (Shulhan Arukh, Yoreh Deah 240:3, 8) and they seem to agree with Ben Sira and Seder Eliyahu — no matter what you parent does, you must obey him (Seder Eliyahu) and not shame him.

But if this is the case, what can a child do if he can no longer bear his parent’s strange or abnormal behavior? This dilemma is dealt with in a third Talmudic passage which became the basis for most subsequent halakhic discussion:

Rav Assi [who lived in Babylon] had an aged mother.

She said to him: “I want jewelry!” He made some for her.

“I want a husband!” He replied: “I’ll look for one for you.”

“I want a husband as handsome as you!”

He left her and went to Israel.

[When] he heard that she was coming after him, he came before Rabbi Yohanan [and] said to him:

“Is it permissible to leave Israel for Hutz La’aretz [the Diaspora]?”

He replied: “It is forbidden.”

[He asked:] “Towards his mother – what is the law?”

He replied: “I don’t know.”

He waited a bit, returned and asked.

[Rabbi Yohanan] said to him:

“Assi, you have decided to leave? May God return you in peace.”

[Rav Assi] came before Rabbi Eleazar.

He said to [Eleazar]: “God forbid, perhaps he is angry at me?”

He said to him: “what did he say to you?”

He said: “May God return you in peace.”

He said to him: “if he was angry, he would not have blessed you”.

In the meantime, [Rav Assi] heard that her coffin was coming.

He said: “Had I known, I would not have leftBabylon!”

[Or: “Had I known, I would not have asked permission to leave Israel!”] (Kiddushin 31b).

This story is very problematic. Was Rav Assi’s mother mentally disturbed (she seems to be interested in marrying her own son) or merely crotchety? Can a child run away when he can no longer tolerate a parent’s erratic behavior? And what does the final ambiguous sentence mean? Did Rav Assi regret abandoning his mother or is he saying that not only did he act properly by leaving her, but he was not even required to meet her coffin?

The halakhic authorities interpreted this story in two conflicting directions. Maimonides (1135-1204) and his followers used it to legitimate custodial care, while Ra’avad of Posquieres (1120-1198) and his followers came to the opposite conclusion.

Maimonides codified the story as follows:

If one’s father or mother should become mentally disordered, he should try to treat them as their mental state demands, until God has pity on them. But if he finds he cannot endure the situation because of their extreme madness, let him leave them and go away, commanding others to care for them as befits them (Hilkhot Mamrim 6:10).

According to the last sentence, it is perfectly legitimate to institutionalize a parent with Alzheimer’s disease, even though this is not explicitly stated in the story about Rav Assi.

This is not a correct ruling! If he goes and leaves him, who shall he command to watch him?!

Apparently, in Ra’avad’s time and place, there was no option of custodial care and, indeed, the first Jewish old age home seems to have been founded in Amsterdam in 1749 (Encyclopaedia Judaica, Vol. 2, col. 346.[/note]

Subsequent halakhic authorities aligned themselves with either Maimonides or Ra’avad. The Maimonidean camp, (R. Shem Tov ibn Gaon (fourteenth century), in Migdal Oz to Maimonides ad loc.; R. Nissim Gerondi (1300-1380), on the Rif to Kiddushin, ed. Vilna, fol. 13a; R. David ibn Zimra (1479-1573) in Radbaz on Maimonides ad loc.; R. Joseph Karo (1488-1575) in Shulkhan Arukh Yoreh Deah 240:10; R. Solomon of Chelm (18th century) in Mirkevet Hamishneh to Maimonides ad loc.; R. Yehiel Michal Epstein (1829-1908) in Arukh Hashulhan, Yoreh Deah 240:32; and R. Eliezer Waldenberg, Tzitz Eliezer, Vol. 12, No. 59).replies that since Rav Assi’s mother was brought to Israel in a coffin, he must have ordered others to take care of his mother. Regarding the practical issue raised by Ra’avad, they reply that the child can hire someone else to take care of the parent. They further state that in cases of a parent who has deteriorated mentally, an outsider can do a better job than a child for two reasons: First of all, the parent will be embarrassed to misbehave in front of an outsider. Secondly, an outsider can raise his voice or physically restrain the parent if necessary, while a child would never be able to do such things and is not allowed to do so.

Ra’avad’s followers reply that it is clear from the end of the story (see the first translation above) that Rav Assi regretted having left his mother and therefore the story proves that custodial care is prohibited (R. Shlomo Luria (1510-1574), Yam Shel Shlomo toKiddushin, chapter 1, paragraph 64; R. Joshua Falk (1555-1614) in Derishah to Tur Yoreh Deah 240; R. Joel Sirkes (1561-1640) in Bayyit Hadashibid.; R. David Halevi (1586-1667) in the Taz to Shulhan
Arukh Yoreh Deah 240:10, subparagraph 14; and R. Samuel Strashun (1794-1872) in Rashash to Kiddushin 31a).Furthermore, if, as Maimonides claims, “others” can take care of the parent, then why can’t the child do so himself since he has a better understanding of his parent’s desires and idiosyncrasies? In addition, this camp seeks support from R. Jacob ben Asher (1270-1343) who in his code (Tur Yoreh Deah 240) quotes Ra’avad after Maimonides, which seems to indicate his agreement with the former. Lastly, this camp asserts that Rav Assi’s mother was not mentally disturbed but old and crotchety. Rav Assi left her because he knew he could not honor her requests properly. But a demented or senile parent needs extraphysical care from the child, while his demented requests can be ignored because he no longer has all of his faculties.

What then are the halakhic options open to a child faced with the dilemma of caring for a parent with Alzheimer’s disease? It appears from the above analysis that there are three legitimate halakhic options:

A child with stamina and emotional fortitude can follow the line of thought expressed by Ben Sira and advocated by the Ra’avad and his camp. They view “honor thy father and thy mother” as an absolute value, which cannot be absolved by the erratic behavior of the parent. Regardless of how the son feels, he must personallytake care of his parents as commanded by the Torah “and do not leave [them] all the days of your life”.

Other children may place their parent in a nursing home, following the example of Rav Assi as interpreted by Maimonides and his followers. According to this view, a child is not personallyobligated to care for the parent, if he must sacrifice his own emotional health in the process. They further state that in cases of mental deterioration, the honor of the parent can be better served by an outsider who can do things the child cannot do and that the parent would not want him to do.

Yet I believe the preferred halakhic solution is one implied by a number of the rabbis in the Maimonidean camp — to keep the parent at home when possible, (The growing phenomenon of adult day care centers enables many children to keep parents with Alzheimer’s at home).but to pay an outsider to attend to the functions which are painful or inappropriate for the child to perform. This solution incorporates the concerns of both Ra’avad and Maimonides. On the one hand, the parent feelswanted and loved by his or her child, a feeling frequently lacking in an institutional setting. The parent functions better at home than in a new and strange environment. Indeed, Midrash Hagadol(to Genesis 35:6, p. 597) relates that in the ancient city of Luz “when a man became disgusted with his father and mother, he would remove them to another city and immediately they would die“. By keeping the parent at home, the child fulfills the commandment to “honor your father and your mother” in a direct and personal fashion as demanded by Ra’avad. On the other hand, following Maimonides, the child protects the parent’s honor and the child’s own emotional health by ensuring that a professional is on hand who can perform functions not in keeping with the honor owed a parent by a child.